Provider Demographics
NPI:1124361811
Name:BLACKPOOL LLC
Entity Type:Organization
Organization Name:BLACKPOOL LLC
Other - Org Name:GEORGIA MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VENKATAPPA
Authorized Official - Middle Name:
Authorized Official - Last Name:RANGARAJ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-218-3468
Mailing Address - Street 1:4415 FRONT NINE DR STE 600
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-6239
Mailing Address - Country:US
Mailing Address - Phone:770-744-7688
Mailing Address - Fax:770-406-1058
Practice Address - Street 1:4415 FRONT NINE DR STE 600
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-6239
Practice Address - Country:US
Practice Address - Phone:770-744-7688
Practice Address - Fax:770-406-1058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-01
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA058633207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003132617AMedicaid
GA003132617AMedicaid